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Clinical Case:


Title: Clinical Case: Author: RW Last modified by: Jordi M. Morell Created Date: 5/4/2000 1:05:31 AM Document presentation format: On-screen Show Other titles – PowerPoint PPT presentation

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Title: Clinical Case:

Clinical Case
  • Mr Veri Pushi
  • 45 year old married self-employed property
  • You are present in casualty when this gentleman
    is brought in by ambulance at 2 am in the

Clinical Case (2)
  • You obtain a quick history from the ambulance
    officers, and then from his wife (who arrives
    shortly afterwards by car).
  • His wife had found him collapsed in the toilet,
    confused and very pale.
  • He had been complaining of abdominal discomfort
    just prior to the collapse, had vomited up some
    altered blood and passed some blackish-red

Clinical Case (3)
  • He had been celebrating the evening before with
    business associates after concluding the sale of
    one of his new retirement home developments.
  • A considerable amount of alcohol had been drunk
    by the gentleman that evening and he had felt
    rough when he arrived home 2 hours previously.
  • His usual alcohol consumption is around 40-50
    units of alcohol per week he has been drinking
    at this level for the last 25 years.

  • What is likely to have occurred with this
  • What is the differential diagnosis?
  • What are your management priorities?

Differential Diagnosis
  • Bleeding peptic ulcer
  • Gastric / duodenal
  • Bleeding oesophageal varices
  • Mallory-Weiss syndrome (Oesophageal Tear)
  • Haemorrhagic alcoholic gastritis
  • Gastric neoplasm eroded bleeding vessel.

Management Priorities
  • Good venous access.
  • Quick assessment of bleed severity.
  • Adequate blood samples
  • Resuscitation of hypovolaemia and hypotension.
  • Assessment of rebleeding risk
  • Elderly / hypotensive on admission
  • Hb lt 8 or HM on admission

Important features to elicit from History
  • Features of hypovolaemia pale, sweaty, pulse
    rate, BP.
  • Previous ulcer disease, GI bleeds
  • Concomitant medical conditions.
  • Anticoagulation therapy.
  • Previous or current liver disease, or risk
    factors for its development (alcohol, parenteral
    blood products, IV drug abuse etc).
  • Stigmata of chronic liver disease.
  • History suggestive of Mallory-Weiss tear?

  • Laboratory
  • FBC
  • Group save / Xmatch (see below)
  • Clotting profile If on anticoagulants, liver
    disease, platelets abnormal, multiple
  • UEs, LFTs
  • CXR
  • When clinically indicated
  • Cardiorespiratory disease / partial gastric
  • ECC
  • when clinically indicated.

His vital signs on admission were
  • BP 90 /50 mm Hg lying unrecordable sitting.
  • Pulse 130/min sinus tachycardia
  • Respiratory rate 25/min
  • Temperature 37.1 C
  • JVP not detectable.

Patient stabilisation
  • Large bore cannulas inserted blood taken.
  • Resuscitation with volume expanders until blood
    is available Haemaccel / Gelofusin
  • Packed red cells used in conjunction.
  • If hypotensive on admission obtain surgical
  • Arrange endoscopy urgency depending on severity
    of bleed and local logistics.

Blood cross-match
  • 1 unit of blood for every 1g/dl that admission Hb
    below 10g/dL.
  • PLUS
  • 4 units if patient is shocked on admission.
  • PLUS
  • 2 units in reserve for a rebleed.

Monitoring management
  • BP Pulse stabilised with resuscitation.
  • Looking for rebleeding signs
  • Fresh haematemesis / malaena in stabilised pt
  • Fall in BP rise in pulse in stabilised pt.
  • Fall in Hb of gt 2g/dl in 24 hours

Unable to stabilise patient
  • Seek senior advice.
  • Consider the need for repeat endoscopy
  • Consider surgical intervention
  • Continued bleeding esp spurting vessel.
  • Rebleeding in hospital
  • 1 rebleed if gt 60 years 2 rebleeds if lt 60 years
  • High transfusion requirement
  • Age gt 50 years 4 units
  • Age lt 50 years 6 units
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